This form is to be completed by the Business Owner, Corporate Officer, or other authorized individual to obtain a user name and password to access the San Mateo County Environmental Health Portal for their regulated facility. Once you are approved as a user by Environmental Health, you can create additional user accounts for your linked facilities. If you are already an authorized user, input the e-mail address linked to the account so the System Administrator can access the existing account and link the new facility. Use the notes section to provide additional information as needed. Someone will contact you to verify the information within 4 working days.

Date*

Information About the Facility

(found on your Environmental Health permit)

Facility Name*

Facility Address*

Facility City*

FA #*

If you have additional facilities, list FA# and facility name

Information About the Business (if different from Facility Info please complete)

(Legal Business Name, Address and Phone Number)

Business Name

Street

City

State

Zip

Phone

Information About You

.

First Name*

Last Name*

Email*

Phone*

Consultants will not be approved as authorized users unless this form is accompanied by a letter signed by the Business Owner or Corporate Officer.